Coverage Trends by Citizenship Status Among Medicaid Income-Eligible Children: 2012-2024

To evaluate coverage correlates and trends by citizenship status among a nationally representative sample of Medicaid income-eligible children. We also examined the associations of coverage policies, including the Affordable Care Act's (ACA's) Medicaid expansion and state-level expansions to children regardless of immigration status, with children's coverage outcomes.

This repeated cross-sectional study used multivariable logistic regression analysis and 2012 to 2024 American Community Survey data. The main sample included children aged 1 to 17 years in all US states with household incomes under the Medicaid income eligibility limit. Binary outcomes included uninsured, Medicaid, and private coverage.

From 2012 to 2024, uninsurance declined from 37.9% to 31.0% among noncitizen children and from 8.2% to 6.1% among citizen children; the coverage gap by citizenship consistently exceeded 20 percentage points. Factors associated with lower uninsured rates among noncitizen children included high parental English proficiency, higher socioeconomic status, living in a metropolitan area, and non-Hispanic Asian ethnicity. The ACA's Medicaid expansion was associated with lower uninsured rates among citizen children, but associations were not statistically significant overall or among noncitizen children. State coverage expansions to children regardless of immigration status were associated with an 8.2 percentage-point reduction in the uninsured rate (95% CI -12.5 to -4.0) before and after their implementation among noncitizen children.

Significant and persistent coverage gaps by citizenship remain among Medicaid income-eligible children. Gaps were substantially ameliorated, although not completely eliminated, in states that expanded their Medicaid programs to cover children regardless of immigration status.